Multiple Reinterventions for Claudication are Associated with Progression to Chronic Limb-Threatening Ischemia

Kim, Tanner; Kiwan, Gathe; Mohamedali, Alaa; Zhang, Yawei; Dardik, Alan; Guzman, Raul J.; Chaar, Cassius Iyad Ochoa

doi:10.1016/j.avsg.2020.10.004

Cited by 11 publications

(4 citation statements)

References 26 publications

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“…A recent, population-based study estimated yearly risk of major amputation at 0.2%, consistent with the estimates in our study 34 . Although revascularization, either by endovascular or surgical means, can improve IC symptoms, suboptimal technical outcomes, and intervention failure can lead to reinterventions and clinical deterioration, negatively altering the clinical course of IC 15 . Indeed, the current meta-analysis confirmed significantly more revascularizations are performed once invasive treatments are initiated.…”

Section: Discussionsupporting

confidence: 91%

“…34 Although revascularization, either by endovascular or surgical means, can improve IC symptoms, suboptimal technical outcomes, and intervention failure can lead to reinterventions and clinical deterioration, negatively altering the clinical course of IC. 15 Indeed, the current meta-analysis confirmed significantly more revascularizations are performed once invasive treatments are initiated. Although reasons for reintervention or revascularization were not available from studies included in this metaanalysis, the additional procedures may have been performed for inherent restenosis or maintenance after EVT rather than progression to CLTI.…”

Section: Discussionmentioning

confidence: 58%

“…Reflecting this ongoing debate regarding the optimal management of IC, the Society for Vascular Surgery Appropriateness Committee is engaged in better defining the nuances of treatment approaches. 15,16 Taken together, the current meta-analysis aimed to address whether risks of progression to CLTI and amputation are increased by invasive treatment for IC using data from performed randomized control trials (RCTs). Differences in outcomes after invasive versus noninvasive strategies regarding total number of subsequent revascularizations performed and all-cause mortality are also analyzed.…”

mentioning

confidence: 99%

“…Furthermore, technical failure, restenosis, and multiple reinterventions may lead to adverse outcomes after invasive treatment. Reflecting this ongoing debate regarding the optimal management of IC, the Society for Vascular Surgery Appropriateness Committee is engaged in better defining the nuances of treatment approaches 15,16 …”

mentioning

confidence: 99%

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Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

et al. 2023

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Objective: The aim was to analyze the risk of progression to chronic limb-threatening ischemia (CLTI), amputation and subsequent interventions after revascularization versus noninvasive therapy in patients with intermittent claudication (IC). Background: Conflicting evidence exists regarding adverse limb outcomes after each treatment strategy. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. MEDLINE, Web of Science, and Google Scholar were searched aided by a health sciences librarian through August 16, 2022. Randomized control trials (RCTs) comparing invasive (endovascular or surgical revascularization) and noninvasive treatment (exercise and/or medical treatment) were included. PROSPERO registration was completed (CRD42022352831). Results: A total of 9 RCTs comprising 1477 patients (invasive, 765 patients; noninvasive, 712 patients) were eligible. During a mean of 3.6-year follow-up, progression to CLTI after invasive [5 (2–8) per 1000 person-years] and noninvasive treatment [6 (3–10) per 1000 person-years] were not statistically different [rate ratio (RR): 0.77; 95% CI, 0.35–1.69; P=0.51, I 2=0%]. Incidence of amputation (RR: 1.69; 95% CI, 0.54–5.26; P=0.36, I 2=0%) and all-cause mortality (hazard ratio: 1.26; 95% CI, 0.91–1.74; P=0.16, I 2=0%) also did not differ between the groups. However, the invasive treatment group underwent significantly more revascularizations (RR: 4.15; 95% CI, 2.80–6.16; P<0.00001, I 2=83%). The results were not changed by fixed effect or random-effects models, nor by sensitivity analysis. Conclusions: Although there is equivalent risk of progression to CLTI, major amputation and all-cause mortality compared with noninvasive treatment, invasive treatment for patients with IC led to significantly more revascularization procedures and should be used selectively in patients with major lifestyle limitation. Guideline recommendation of noninvasive treatment for first-line IC therapy is supported.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 58%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

et al. 2023

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An audit of secondary prevention for peripheral arterial disease in primary care — scope for improved collaboration between vascular surgery and general practitioners

2023

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Background Symptomatic peripheral arterial disease (PAD) is a common cause for referral from primary care to vascular surgery. Best medical therapy (BMT), encompassing anti-platelets, statins, smoking cessation, blood pressure and glycaemic control, is a cornerstone of PAD management. However, these easily modifiable risk factors are often left unaddressed between referral and clinic review. Methods A prospective audit of electronic ‘Healthlink’ referrals by GPs to the vascular department for symptomatic PAD between July 2021 and June 2022 was performed. Referrals were individually reviewed for demographics, symptoms, medical history, smoking status and medications. An information leaflet on BMT was posted to all GP practices in the Soalta region as part of an educational intervention, with plans to re-audit after 6 months. Results One-hundred-and-seventy referrals were analysed. The median age was 68.5 years (range 33–94) and 69% (n = 117) were male. The typical vasculopath comorbidity profile was noted. Fifty-two percent (n = 88) were referred with claudication-type pain and 25% (n = 43) with critical limb ischaemia (CLI). Twenty-eight percent (n = 33) were active smokers and 31% (n = 36) had no smoking status documented. Regarding BMT, only 34.5% (n = 40) and 52% (n = 60) were on anti-platelets and statins, respectively. Suspected CLI was not significantly associated with BMT prescription at referral (p = 0.664). Only eleven referral letters mentioned risk factor optimisation. Conclusions Our first-cycle results identified significant scope for improvement in community-based risk factor modification for PAD referrals. We aim to continue supporting and educating our colleagues that effective medical management can start safely in primary care and further explore the barriers preventing this.

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Insulin Requirement and Infrainguinal Bypass Outcomes in Patients with Peripheral Arterial Disease

Alameddine,

Satam,

Slade

et al. 2024

Annals of Vascular Surgery

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Multiple Reinterventions for Claudication are Associated with Progression to Chronic Limb-Threatening Ischemia

Cited by 11 publications

References 26 publications

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

An audit of secondary prevention for peripheral arterial disease in primary care — scope for improved collaboration between vascular surgery and general practitioners

Insulin Requirement and Infrainguinal Bypass Outcomes in Patients with Peripheral Arterial Disease

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